A mock-drill study conducted in a third of North
Carolina's hospital emergency departments revealed that
nearly all failed to properly stabilize seriously injured
children during trauma simulations, according to a team of
researchers at the
Johns Hopkins
Children's Center and Duke University Medical
Center.
Simulations were conducted in 35 of North Carolina's
106 emergency departments; of the 35, five were designated
trauma centers (out of a total of 11 in North Carolina),
and 30 were located in community hospitals. A report on the
work by the research team, stating that the results
probably apply to hospitals nationwide, is published in the
March issue of Pediatrics.
Although researchers caution that observations during
mock "codes" do not necessarily represent performance in an
actual health emergency, the study's results do suggest
that hospital EDs are not fully prepared to deal with
pediatric emergencies, according to lead author Elizabeth
A. Hunt, assistant professor of
anesthesiology and critical care medicine at Johns
Hopkins.
Hunt and colleagues staged "mock codes," using
life-size child mannequins. They presented each ED team
with a vignette describing the patient's symptoms,
appearance and vital signs. Researchers then observed and
rated the team's performance on 44 stabilization tasks,
such as evaluating an airway, administering fluids and
ordering appropriate tests.
None of the departments performed flawlessly, Hunt
said, and while mistakes were ubiquitous, certain failures
were more worrisome than others. For example, of the 35 EDs
studied, 34 failed to administer dextrose properly to a
child in hypoglycemic shock (a life-threatening sharp drop
in blood sugar). Also, 34 of 35 failed to correctly warm a
hypothermic child.
Thirty-one of the 35 also failed to order proper
administration of IV fluids, and personnel in 24 out of 35
did not either attempt or succeed at accessing a child's
bloodstream through a bone, a critical alternate avenue for
rapidly delivering fluids and medicines to sick children
whose veins may have constricted due to hypothermia or
blood loss.
Researchers said they were surprised to find that
emergency medicine staff failed to follow safe patient
transport procedures. Only 12 of the 35 hospitals prepared
appropriate medications, monitoring equipment and personnel
needed to transport a child safely within the hospital. The
observation adds new insight to why transportation within
the hospital is a high-risk time for patients, Hunt
said.
Despite the failures, Hunt said, departments
successfully handled many of the 44 mock code tasks well,
including calling appropriate members for assistance,
initial airway assessment, initiating bag-mask ventilation,
ordering appropriate imaging tests and initial vital signs
assessment.
"There is no definitive evidence to say whether
performance during simulation reflects performance during
actual events," Hunt said. "However, this study gives us
very specific targets for attempting to improve
stabilization procedures for children." For example, Hunt
suggests hospitals conduct periodic drills to look for
recurrent patterns that identify areas most vulnerable to
error.
Trauma is the No. 1 cause of death among children,
according to the Centers for Disease Control and
Prevention. Of the 30 million children who seek treatment
in emergency departments each year, 81 percent are treated
in community hospitals, such as the majority of the
hospitals in this study.
Funding for this research was provided by the state of
North Carolina.
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